Medically unexplained physical symptoms in patients visiting the emergency department: an international multicentre retrospective study

M.U.P.S (Medically Unexplained Physical Symptoms): Is the Accurate Diagnosis Necessary for the Rehab-Team?

Background: Physiatrists often treat patients with medically unexplained symptoms (MUPS), which suggest various psychiatric, psychosomatic or physical diagnoses. Some patients are finally diagnosed with somatoform, dissociative or factitious disorders, while some experience psychological factors affecting physical conditions. It happens that patients are admitted to rehabilitative medical facilities without a clear diagnosis. Apparently, there are overlapping symptoms between chronic fatigue syndrome, PTSD (post-traumatic stress disorder), "Gulf War syndrome", fibromyalgia, CRPS, and others.Aims: To assess recognition of medically unexplained physical symptoms (MUPS) by physicians, mostly specialists in physical and rehabilitative medicine are engaged.Methods: All information was collected from scientific database site, and derived from the authors' nearly 50 years of clinical experience.Results: Cognitive-affective disturbance, chronic muscle and joint pain, panic disorder, chronic fatigue syndrome, malingering, and others can be described in the medical literature as unexplained physical symptoms.Conclusions: Treatment should comprise a multidisciplinary-integrative approach, by practitioners from medicine, psychology, allied health professionals and social work. MUPS is not a "non-disease" entity, but rather, an unexplained clinical phenomenon. Patients are entitled to benefit from the rehabilitative medicine model of treatment even if their clinical diagnosis is not accurate or clear.

Medical educators' experiences on medically unexplained symptoms and intercultural communication-an expert focus group study

BACKGROUND

Medically unexplained symptoms (MUS) are highly prevalent and remain challenging in healthcare and medical education, along with the increase in the importance of intercultural issues regarding MUS. However, less is known about the challenges of professionally addressing patients with MUS in the interprofessional and intercultural contexts. Thus, the present study aims to provide the first exploration of the experiences of medical specialists regarding treating MUS in intercultural contexts and inputs for training development on the intercultural aspects of MUS.

METHODS

Three focus groups (total n = 13) consisting of medical specialists from a Hungarian university who were teaching at the medical faculty in intercultural settings and also worked for the university health services were interviewed. The topics covered the participants' personal experiences on addressing MUS and the challenges of intercultural communication and the intercultural educational context. Thematic analysis was used to yield a qualitative account of the interviews as guided by the research questions.

RESULTS

Representing the different aspects of medical specialists, the study identified three main themes in the experiences of medical specialists, namely, 1) the need to adapt to the personal world of patients and search for common frames to understand MUS, 2) the need to discover methods for adapting to cultural differences and 3) the need to enhance the interprofessional coordination of knowledge and practices.

CONCLUSIONS

The results are in line with the distinct conclusions of previous studies. Moreover, an integrated educational program on the intercultural aspects of MUS may address the main themes separately and, subsequently, support their integration. Therefore, the study discusses the manner in which an integrated educational program on the intercultural aspects of MUS may address the needs recognized in these aspects.

Epidemiology and organisation of care in medically unexplained symptoms: A systematic review with a focus on cultural diversity and migrants

BACKGROUND

Since the pathophysiology of medically unexplained symptoms (MUS) remains unclear, healthcare providers often struggle with these patients, especially with a different ethnic and/or cultural background. These challenges are insufficiently addressed in their training and in the organisation of care.

AIM

To improve healthcare provider-patient interaction focused on MUS patients in general and in ethnic minorities and refugees in particular through a systematic review of syndromal definitions and epidemiology and organisation of care of MUS patients.

METHODS

Screening of PubMed, Web of Science, Cinahl and Cochrane Library on the keywords 'Medical unexplained (physical) symptoms (MUPS)', 'Somatoform disorder', 'Functional syndrome', 'Diversity', 'Migrants', 'Ethnicity', 'Care models', 'Medical education', 'Communication skills', 'Health literacy'.

RESULTS

Different case definitions result in markedly different epidemiological estimates for MUS patients. Nevertheless, they are prevalent in a wide range of healthcare settings. Literature offers evidence of the effectiveness of structural frameworks in approaching MUS patients. Organisation of MUS care needs to transcend different levels of care: specialist tertiary and secondary care and primary care involving different qualifications of caregivers need to be aligned.

CONCLUSION

The systematic review identified significant gaps and shortcomings in organisation of care. These need to be addressed in order to improve outcomes.

Pediatric somatization in the emergency department: assessing missed opportunities for early management

OBJECTIVE

Somatization is a common phenomenon that can severely complicate youths' functioning and health. The burden of somatization on pediatric acute care settings is currently unclear; better understanding it may address challenges clinicians experience in effectively caring for somatizing patients. In this study, we estimate the prevalence of somatization in a pediatric emergency department (ED).

METHODS

We conducted a retrospective cross-sectional study of visits for non-critical, non-mental health-related concerns (n = 150) to a quaternary-level pediatric ED between July 2016 and August 2017. Demographic and clinical visit details were collected through chart review and used by two reviewing clinicians to classify whether each visit had a "probable," "unclear" (possible), or "unlikely" somatizing component.

RESULTS

Approximately 3.33% (n = 5) of youth displayed probable somatization, and an additional 13.33% (n = 20) possibly experienced a somatizing component but require additional psychosocial and visit documentation to be certain. Longer symptom duration and multiple negative diagnostic tests were associated with a higher likelihood of either probable or possible somatization.

CONCLUSIONS

A considerable proportion of non-mental health-related visits may involve a somatizing component, indicating the burden of mental health concerns on the ED may be underestimated. A higher index of suspicion for the possibility of somatization may support clinicians in managing somatizing patients.

A comparison of emergency department presentations for medically unexplained symptoms in frequent attenders during COVID-19

Medically unexplained symptoms (MUS) are those with no identified organic aetiology. Our emergency department (ED) perceived an increase in MUS frequency during COVID-19. The primary aim was to compare MUS incidence in frequent attenders (FAs) during COVID-19 and a control period.A retrospective list of FA-MUS presenting to our ED from March to June 2019 (control) and March to June 2020 (during COVID-19) was compared. Fisher's exact test was used to compare binomial proportions; this presented as relative risk (RR) with 95% confidence intervals (95%CI).During COVID-19, ED attendances reduced by 32.7%, with a significant increase in the incidence of FA-MUS and FA-MUS ED visits compared to control; RR 1.5 (95%CI 1.1-1.8) p=0.0006, and RR 1.8 (95%CI 1.6-2.0), p<0.0001, respectively.Despite reduced ED attendances during COVID-19, there was a significant increase in the incidence of FA-MUS patients and corresponding ED visits by this cohort. This presents a challenge to ED clinicians who may feel underprepared to manage these patients effectively.

Diagnostic error in the emergency department: learning from national patient safety incident report analysis

BACKGROUND

Diagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. We sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015 and to identify the priority areas for intervention to reduce their occurrence.

METHODS

A cross-sectional mixed-methods design using an exploratory descriptive analysis and thematic analysis of patient safety incident reports. Primary data were extracted from a national database of patient safety incidents. Reports were filtered for emergency department settings, diagnostic error (as classified by the reporter), from 2013 to 2015. These were analysed for the chain of events, contributory factors and harm outcomes.

RESULTS

There were 2288 cases of confirmed diagnostic error: 1973 (86%) delayed and 315 (14%) wrong diagnoses. One in seven incidents were reported to have severe harm or death. Fractures were the most common condition (44%), with cervical-spine and neck of femur the most frequent types. Other common conditions included myocardial infarctions (7%) and intracranial bleeds (6%). Incidents involving both delayed and wrong diagnoses were associated with insufficient assessment, misinterpretation of diagnostic investigations and failure to order investigations. Contributory factors were predominantly human factors, including staff mistakes, healthcare professionals' inadequate skillset or knowledge and not following protocols.

CONCLUSIONS

Systems modifications are needed that provide clinicians with better support in performing patient assessment and investigation interpretation. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements.

Medically Unexplained Physical Symptoms in Hospitalized Patients: A 9-Year Retrospective Observational Study

Introduction: "Medically Unexplained Physical Symptoms" (MUPS) defines a subgroup of patients presenting physical symptoms of unclear origin. The study aims to profile clinical and socio-demographic characteristics of patients with MUPS. Materials and Methods: This 9-years observational retrospective study assesses all patients admitted between 2008 and 2016 in the divisions of neurology and gastroenterology. Socio-demographic and clinical variables were evaluated: gender, age, diagnosis or diagnostic hypothesis, presence of psychiatric comorbidities, psychiatric evaluation, pharmacological treatment, number of admissions/visits. Results: Among 2,479 neurological patients 10.1% presented MUPS. Patients were more frequently women (63.5%), with a mean age of about 50 years. Reported symptoms were headache (22.6%), seizures (8.7%), vertigo (5.9%), fibromyalgia (5.5%), paresthesia (5.1%), visual disturbances (5.1%), amnesia (3.9%). The diagnosis was somatoform disorder in 6.3% of cases, conversion disorder in 2.7%, and somatic symptom disorder in 1.5% only. 2,560 outpatients were evaluated in gastroenterology division. 9.6% (n = 248) of patients had MUPS; 62.1% of them were women. The most affected age group ranged between 15 and 45 years. The most frequent diagnoses were functional abdominal pain (50%), dysmotility-like dyspepsia (26.6%), irritable bowel syndrome (10.4%), meteorism of unknown cause (2.4%), hiccup (1.6%), burning mouth syndrome (1.2%). No patients received a diagnosis of somatic symptom disorder. Discussion: Patients with MUPS are more often women, of middle age, with self-referred specific symptomatology. While neurological patients received a diagnostic-therapeutic approach in line with the literature, gastroenterological patients mainly received antipsychotics. A more comprehensive assessment and a development of psychoeducational interventions are needed to improve patients' quality and quantity of life.